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Address
City
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Zip
Date of birth
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Please Notify
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Physician
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Agreement	I agree that I have completed the foregoing information to the best of my knowledge. I also agree to hold harmless VIP Medical Systems from any and all liability arising from the use of and/or reliance on the foregoing by any person or entity. Checking this agreement must be by parent guardian if cardholder is under 18 years of age.
Please Check	Print Form Back I agree to the above terms

Emergency Medical ID Card

Check all that apply

TO ORDER YOUR EMERGENCY MEDICAL ID
Complete all the data forms and click the "submit" button.
at the bottom of this page. If you wish to order more that one ID
Card, reset the form data and fill out another data form for

	Please Send Me	Amount
Emergency ID Card (without photo)	EMERGENCY MEDICAL ID CARD (No photo)	$24.99
Emergency ID Card(with photo)	EMERGENCY MEDICAL PHOTO ID CARD	29.99
Medical ID Bracelet, Necklace, Sterling Silver	MEDICAL ID BRACELET MEDICAL ID NECKLACE	99.95
Medical ID Bracelet, Necklace, Gold Filled	MEDICAL ID BRACELET MEDICAL NECKLACE	179.95
Breifcase Calculator	BRIEFCASE CALCULATOR	9.95
Lighted Medical ID Card Holder	LIGHTED MEDICAL ID CARD HOLDER	9.95
Recognizing Stress Slide Guide	Recognizing Stress Slide Guide	4.50
	BONUS GIFT (Check one) RECOGNIZING STRESS LIGHTED ID CARD HOLDER BRIEFCASE CALCULATOR

If you order a Photo ID Card you must supply us with a photo (recent)
You can either mail it or attach it to a email.

Email to, number1@hurtsvip.com or
Mail to:
            VIP Medical ID Systems
            P.O. Box 39152
            Indianapolis, IN 46239

Text Box:

Your photo here

Drivers Licenses No.
Name
Address
Address Cont
City
State
Zip Code
Telephone
In Emergency Notify
Telephone

Item Name: Test
Item Number: 100
Price: $10.00

Blood Type
Soc Sec No.
Insurance Co.
Policy No.
Telephone
Religion